Losing Sleep over Mary Brown: SCOTUS and You
Mary Brown is a small business owner in Panama City, FL, who complained to her local Chamber of Commerce that the Patient Protection and Affordable Care Act (PPACA) would bankrupt her business. The Pensacola Chamber sued in district court, and Mary Brown became the plaintiff for the court case that ended up on the Supreme Court’s doorstep.
As a result, the Supreme Court of the U.S. (SCOTUS) will hear arguments spanning three days in a case that will determine, in part, the fate of the PPACA. On March 26, the Court will hear arguments concerning their ability to rule prior to 2014 (when key provisions will be implemented and thus potentially create “damages”). On March 27, the constitutionality of the individual mandate will be reviewed, and on March 28, the court will review which parts of the PPACA are linked to the mandate and whether Medicaid expansion is constitutional. A decision is expected by June 30.
What does this mean for you? Lots. First, let’s deal with Medicaid expansion. We all worry that average patient reimbursement will be reduced to rates approximating Medicaid if employers decide to have their employees join a state health exchange or if a large number of previously uninsured patients become covered at Medicaid rates. Some states are counting on SCOTUS to strike Medicaid expansion as unconstitutional. They should read “All Heat, No Light — The States’ Medicaid Claims before the Supreme Court” by Sara Rosenbaum, JD, and Timothy Stoltzfus Jost, JD (N Engl J Med 2012; 366:487-489. Feb 9, 2012). It is unlikely that this portion of the PPACA will be overturned. An analysis by Thomson Reuter’s health-care division offers some comfort since 12 states plus DC will not see expansion of Medicaid because of the uninsured. Other states, however, will see a large number of uninsured become Medicaid-eligible through exchanges. You will need this information to anticipate changes in your payor mix.
Now, to SCOTUS and the impact on exchanges. David K. Jones writes a succinct article that you should read — The Fate of Health Care Reform – What to Expect in 2012 (N Engl J Med 2012; 366:e7. Jan. 26, 2012) — about four key events that could affect health-care reform this year. Also, for those of you who attended the recent AGA Clinical Congress in Miami, you’ll remember that I discussed these issues during the keynote speech. Twenty-six states joined the current lawsuit and are betting that the individual mandate will be struck down. If that doesn’t occur, they hope that President Obama will be defeated and PPACA will be repealed or its implementation slowed. The deadline for states to apply for federal grants to support the creation of health exchanges is June 29. Therefore, if SCOTUS supports the constitutionality of the individual mandate, many states, whose legislatures meet January to June, will have insufficient time to pass legislation creating exchanges. Those states will likely have to accept a federal exchange, thus losing flexibility in designing their own. This is a dangerous gamble. Gastroenterologists need to understand their own states’ dynamics. Now is the time to become involved in a grassroots political effort.
As these events play out in rapid succession, I am committed, as is the AGA, to keeping you informed about implications for your practice. Your margin for error is diminishing, but the opportunity to provide critical health care for patients has not.
Do not make rash decisions. At the end of the day, if you have prepared for the future by implementing an electronic medical record, joining the outcomes registry, maintaining good relationships with your regional health-care systems, preparing to produce valid outcome (not process) measures about your colonoscopies and inflammatory bowel disease care, and conducted an internal lean analysis, you will be fine. AGA will help as it rolls out the Roadmap to the Future of GI (continue to read Clinical Gastroenterology and Hepatology for more information on the roadmap in July 2012).
We still have much to offer patients. They are counting on us to get this right.